St.Vincent Health Health Career Opportunity Program (HCOP) College Prep ACADEMY 9 th - 12 th Grade Students April 21, 2012 - September 8, 2012 Enter to learn...leave to serve Metropolitan Indianapolis-Central Indiana Area Health Education Center St.Vincent MICI-AHEC is now accepting applications for the HCOP College Prep Academy, a 20-week Saturday academic program for high school students with an interest in the health care field. College Prep Academy is geared toward students interested in learning educational skills needed to apply and become accepted in a health-related school. This program focuses on: enhancing math and science understanding comprehension of reading and effective writing skills developing computer skills for research experience SAT/ACT and college preparation workshops to prepare students for health-related schools Program dates: April 21, 2012 - September 1, 2012 (Ceremony September 8, 2012) Details: 9th-12th grade students are paid a stipend for participating for the duration of the program Students attend classes every Saturday from 9:00 a.m. to 3:30 p.m. Priority will be given to JAG students (Jobs for America s Graduates) Location: St. Vincent Hospital (classrooms-basement of hospital) 2001 W 86th Street Indianapolis, IN 46260 Return application and documents to: St. Vincent Health MICI-AHEC 9101 N Wesleyan Road, Suite 310 Indianapolis, IN 46268 (317) 583-3512 MICI-AHEC.stvincent.org College Prep Academy is supported by the following organizations: Metropolitan Indianapolis-Central Indiana Area Health Education Center IU School of Health and Rehabilitation Sciences National Organization for the Professional Advancement of Black Chemists and Chemical Engineers (NOBCChE) EmployIndy
Participant Application Student Name: Gender: Female Male Date of Birth: Age: Cell Phone: Home Phone: Street Address: City: State: Zip Code: Student Email Address: Parent Name(s): Parent Day time Phone: Email Address: Grade entering in Fall of 2012: Name of School: School Address: GPA: /4.0 scale Health career area of Interest: Race (Check One): African American/Black Hispanic White/Non-Hispanic Asian American Indian/Alaskan Native Other (please specify) Would you be the first in your immediate family to graduate from a college or university? Yes No Shirt Size Are you a JAG student? Yes No Vegetarian Meal Required? Yes No How did you hear about the program? School teacher Family member HCOP representative KIHC presentation Internet How interested in health care are you: Very Somewhat Not really Not sure yet Does your mother/guardian have a college degree? Yes No, if yes where Does your father/guardian have a college degree? Yes No, if yes where I hereby certify that the information provided in this application is accurate to the best of my knowledge. I understand that providing false information can result in dismissal from the program if I am accepted to the program. I understand that submitting this application does not guarantee admission to the College Prep Academy. Applicant Signature: Date: Parent/Guardian s signature: Date:
Academic Recommendation Form I have known the applicant for a period of in the following capacity: Please check one Math Teacher Science Teacher Counselor Other, indicate: The applicant ranks academically with other students I have taught in recent years as follows: Top 5% Top 10% Top 25% Average Below Average Please rank the applicant on the following traits, relative to the other students you have taught. CHARACTERISTIC Intellectual Ability 5 4 3 2 1 Excellent Good Average Fair Poor N/A Communication Skills Emotional Stability Comprehension Accuracy/ Attention to Detail Maturity/Judgment Motivation/Perseverance Dependability Cooperative Attitude Leadership (Potential) The applicant is: Recommended with Confidence Recommended with Reservations Recommended Not Recommended Please attach a 1 2 paragraph description of your reasons for recommending this student. RECOMMENDED BY: Name: Title: Department: School Name Address: City/State/Zip: Phone number where you can be reached: Signature: Date:
Academic Recommendation Form I have known the applicant for a period of in the following capacity: Please check one Math Teacher Science Teacher Counselor Other, indicate: The applicant ranks academically with other students I have taught in recent years as follows: Top 5% Top 10% Top 25% Average Below Average Please rank the applicant on the following traits, relative to the other students you have taught. CHARACTERISTIC Intellectual Ability 5 4 3 2 1 Excellent Good Average Fair Poor N/A Communication Skills Emotional Stability Comprehension Accuracy/ Attention to Detail Maturity/Judgment Motivation/Perseverance Dependability Cooperative Attitude Leadership (Potential) The applicant is: Recommended with Confidence Recommended with Reservations Recommended Not Recommended Please attach a 1 2 paragraph description of your reasons for recommending this student. RECOMMENDED BY: Name: Title: Department: School Name Address: City/State/Zip: Phone number where you can be reached: Signature: Date:
MICI-AHEC College Prep Academy 2012 Personal Recommendation Form I have known the applicant for a period of Relationship to applicant: Please rank the applicant on the following traits: CHARACTERISTIC Intellectual Ability Communication Skills Emotional Stability Comprehension Accuracy/ Attention to Detail Maturity/Judgment Motivation/Perseverance Dependability Cooperative Attitude Leadership (Potential) 5 4 3 2 1 Excellent Good Average Fair Poor N/A The ability of the applicant to pursue an undergraduate science or health program is perceived as follows: Excellent Good Average Fair Poor Unsatisfactory The applicant is: Recommended with Confidence Recommended with Reservations Recommended Not Recommended Any additional comments: *Please attach a 1 2 paragraph description of your reasons for recommending this student. RECOMMENDED BY: Name: Title: Department: School Name Address: City/State/Zip: Phone number where you can be reached: Signature: Date:
Application Checklist: completed application academic transcript letter of reference (2 academic recommendations, 1 personal recommendation) recommendation form filled out Personal statement of interest Mail or fax completed application to: Metropolitan Indianapolis-Central Indiana Area Health Education Center 9101 Wesleyan Road, Suite 310 Indianapolis, IN 46268 317-583-3512 Fax: 317-583-4112 For Questions: MICIregistration@stvincent.org Application deadline: March 28, 2012 (All applications must be postmarked by March 28, 2012 to be considered). Metropolitan Indianapolis-Central Indiana Area Health Education Center